An 11-year-old boy presents to the emergency room (ER) with a 4-inch laceration on his right arm. He was with his friends doing bicycle stunts when he fell off his bike and cut his arm on a rusty nail
An 11-year-old boy presents to the emergency room (ER) with a 4-inch laceration on his right arm. He was with his friends doing bicycle stunts when he fell off his bike and cut his arm on a rusty nail from the ramp. In addition, his wrist is swollen, bruised, tender to touch, and warm, with limited mobility. He will most likely need stitches to close the laceration and a splint for the sprain.
In your initial post answer the following questions:
After treatment, as he prepares to leave, you give him last-minute care instructions for laceration and sprain. What would be important for this boy to know to prevent further health concerns with his injuries?
What is most important for the kid to know regarding his sprain and laceration is to refrain from using the joint and keep his wound site clean and dry. Immobilization will likely be included in his treatment plan. Muscle contraction near the affected joint can cause improper healing (Grossman & Porth, 2013). Also, monitoring the site for signs of infection is important especially since the wound is deep and prone to infection. Micro-organisms from the rusty nail likely contaminated it. The most serious risk associated with his injuries is an infection (Worster, Zawora, & Hsieh, 2015).
Accidental falls are the primary cause of nonfatal injuries seen in children and adolescents in the United States, according to the 2017 report from the national Centers for Disease Control and Prevention(CDC). Falls in this age group account for approximately 2.8 million trips to the emergency department each year (CDC, 2017). The cause of this child’s injury is not atypical, given this demographic’s propensity for physical activity and sports.
Joints are considered the weakest parts of the skeletal system and are common sites for injury because of forced twisting or stretching (Grossman & Porth, 2013). Ligament injuries are among the most common causes of musculoskeletal joint pain and disability (Hauser et al., 2013). The boy’s injury was caused by either over-stretching or extreme twisting of his right wrist during the fall from his bike (Grossman & Porth, 2013). The scapholunate interosseus ligament is the most common ligament involved in these injuries(White & Rollick, 2015). The extent of his injury depends on how damaged his ligament is. He required a splint, so, he probably suffered at least a small tear. A sprain can range in severity from mild, where the ligament is partially torn, to severe, where the ligament is completely torn (Grossman & Porth, 2013).In addition to his symptoms and clinical presentation, snapping, clicking, grinding, or disability may be noted with sprains(White & Rollick, 2015; Grossman & Porth, 2013). Examination may also reveal a weak grip and a decreased range of motion(White & Rollick, 2015). Generally, the pain associated with a sprain is more intense and lasts longer than the pain experienced by a strain (Grossman & Porth, 2013). A diagnostic arthroscopy is a gold standard for the diagnosis of both acute and chronic scapholunate ligament injuries(White & Rollick, 2015). In a case like this one, an exam is enough for diagnosis (White & Rollick, 2015). The patient should be discouraged from applying heat and massaging the area because it will cause swelling and bleeding. For many years, the PRICE (protection, rest, ice, compression and elevation)method has been the central treatment paradigm for the management of acute soft tissue injury(Norton, 2016).
His wrist will need to be immobilized in a splint for several weeks because sprains heal slowly (Grossman & Porth, 2013). Rehabilitation may be necessary. Keeping the affected joint immobilized is important because muscle contraction too early can cause the ligament to tear away and cause reinjury. If this happens, the tendon can heal in a lengthened position interfering with joint use later (Grossman & Porth, 2013). A long-term complication related to a poorly healed ligament injury is osteoarthritis (Hauser et al., 2013).
Next, it will be important for the boy to understand that taking good care of his laceration will help to prevent complications. A laceration is defined as a soft tissue injury where the skin is either torn or its integrity is disrupted. The severity of a laceration is determined by its size, depth, and whether it is contaminated. The boy’s wound could have been contaminated by a microorganism, C. tetani, from the rusty nail. C. tetani is a bacterium commonly found in soil, which causes tetanus, or lockjaw (Hamborsky, Kroger, & Wolfe, 2015). Tetanus immunization is recommended for children in the U.S. and boosters are administered every ten years to ensure immunity. The4-inch wound should have been thoroughly irrigated, cleansed using antimicrobials, and left open to prevent anaerobic infection or sinus tracts (Grossman & Porth, 2013). If the child has not received his tetanus booster, this is something he should be offered before him leaving the facility. After thorough wound cleansing and immunization against C. tetani, there is still a risk that micro-organisms can colonize the wound.
Skin serves as a protective barrier that prevents the entry of microorganisms into the body. A break in the skin can cause micro-organisms that are normally localized to the skin surface to gain entry to underlying tissues. Keeping the wound clean and dry, as well as the areas surrounding the wound will help prevent infection. Staphylococcus aureus (S. aureus), Pseudomonas aeruginosa (P. aeruginosa), and β-hemolytic streptococci are the most common bacteria found in infected and non-infected wounds (Guo &Dipietro, 2010).S. aureus is an opportunistic pathogen that can be harmful depending on its location and the conditions for pathogenicity. S. aureus is also a type of commensal bacterium present on human skin and mucous surfaces. Keeping the areas around his laceration clean is important for preventing the entry of commensal, opportunistic bacteria such as S. aureus. Avoiding swimming and contact with potentially contaminated surfaces and objects should also be communicated to the boy. An infected wound can infect the nearby tissue and lead to a massive infection that spreads to the bloodstream (sepsis). Aftercare instructions to prevent infection are important.
Soft tissue injuries can impact ligaments, nerves, joints, blood vessels, and muscles so diligent care measures after treatment are important for optimizing tissue healing. As long as the factors I discussed do not occur, including infection and muscle use before complete healing, the child’s soft tissue injuries should heal properly with no residual disability/deformity.
A basic understanding of healing is necessary to restore any soft tissue injury properly. A soft tissue injury is an injury to the muscle, ligament, tendon, or any other connective tissue, such as skin, fat, myofascial tissue, and joint capsules (Grossman & Porth, 2013; Hauser et al., 2013). There are three major steps that soft tissue goes through when it heals: an inflammatory phase, proliferative or regenerative/repair phase, and a tissue remodeling phase (Hauser et al., 2013).
The acute inflammatory phase starts almost immediately after the injury. Blood collects at the site of injury, and blood components initiate their cascade of events, which will end in clot formation (Grossman & Porth, 2013). Growth factors are released from the fibrin clot and disperse into the surrounding tissue. The growth factors responsible for initiating soft tissue healing during the inflammatory phase include platelet-derived growth factor (PDGF), transforming growth factor-β (TGF- β), vascular endothelial growth factor (VEGF), and fibroblast growth factor (FGF).PDGF and TGF- β will attract immune cells to the injured tissue then stimulate their proliferation (Grossman & Porth, 2013). Inflammation will occur over the injury as a result of the actions of the immune system working to remove dead tissue and contaminants (neutrophils and monocytes) and initiate tissue repair( growth factors). The classic signs of inflammation are a pain, erythema, swelling, loss of function, and heat. The VEGFwill induce the formation of new blood vessels, which will restore blood flow to the area. FGF will promote the growth of new fibroblasts for the production of collagen and cartilage.
The proliferative phase starts when immune cells release growth factors and cytokines that initiate the rebuilding of the tissue (Hauser, 2013). Fibroblasts deposit different types of collagen and glycoproteins into the tissue matrix (Grossman & Porth, 2013). The new collagen will start to become aligned with existing tissue during this phase. The boy’s ligament will be repaired in the proliferative phase, but the newly formed collagen will not be the same size and shape as a normal ligament. The same will be true with his laceration during the proliferation phase. The newly formed tissue over the laceration will be fragile and not the same as the surrounding skin. The new tissue formed during this phase of healing will be disorganized and unstable. As a result, the child will need to be careful not to reinjure the ligament or the laceration (Grossman & Porth, 2013; Hauser, 2013).
After collagen is replaced, the proliferative phase transitions into the remodeling phase (Hauser, 2013). In the remodeling phase, the collagen fibers mature which can take months to years in some soft tissue injuries (Hauser, 2013). During this maturation phase, the tissue starts to look more normal, but its structure and function may still be abnormal (Hauser, 2013). After healing, the boy may not regain full strength in his wrist joint, and he may have scarred over the site of the laceration.
The boy concernedly asks you, “My uncle lost his foot because he got gangrene in it. Am I
going to lose my arm if I get an infection in this cut?” How would you respond?
Gas gangrene is a life-threatening infection mainly caused by one of several Clostridium bacteria, most commonly Clostridium perfringens(C. perfringens)(Grossman & Porth, 2013).C. perfringens is an anaerobic, opportunistic, gram-positive, spore-forming microbe capable of contaminating, then colonizing deep muscle tissue. They proliferate and thrive in anaerobic (no oxygen) environments(LA Department of Health and Hospitals, 2015). They release an exotoxin that destroys surrounding muscle tissue. Injury is extensive, and without proper treatment and healing, the affected tissue becomes necrotic and can lead to sepsis.C. perfringenscan be found in raw meats in soil, and it has found to be a part of normal gut flora (Grossman & Porth, 2013). Risk factors for gas gangrene include recent injury, trauma, or surgery (Grossman & Porth, 2013). The bacterium survives as a spore for 6 to 24 hours before it germinates in an anaerobic tissue and begins replication (LA Department of Health and Hospitals, 2015).
The boy does have risk factors for C. Perfringensinfection, but if his laceration injury was cleansed, irrigated, and treated properly immediately after the accident, his risks for contracting this pathogen should be slim. All contaminants and debris are removed during wound cleansing. He would be at risk for contracting an infection associated with skin surface opportunistic bacteria like Staph. His uncle lost his foot as a result of the infection spreading and causing necrosis. His foot was likely surgically amputated to prevent the spread of the disease. There could have been other factors associated with his uncle’s disease process like the presence of vascular disease, chronic conditions (i.e., diabetes), poor wound management, age, immunocompromised, and immobility. Wound care management can how well his injuries heal. I would encourage him to follow the provider’s instructions and keep his wound clean. He will be susceptible to infection with any break in the skin.
References
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